10.3 Postoperative Emergencies: Bleeding, Infection, Emboli

Postoperative Hemorrhage and Hypovolemic Shock

Hemorrhage is the most dangerous early postoperative emergency, caused by a slipped ligature, an unclamped vessel, a dislodged clot, or coagulopathy. Recognition hinges on knowing the sequence: tachycardia is the earliest sign as the body compensates, followed by tachypnea, anxiety and restlessness, pallor, and cool, clammy skin. Hypotension is a LATE sign — by the time blood pressure falls, the patient has lost substantial volume. Other clues include narrowed pulse pressure, urine output below 30 mL/hour, rapidly increasing sanguineous drain output, and wound swelling or hematoma.

Response: apply direct pressure to any external bleeding, ensure large-bore IV access, rapidly infuse isotonic crystalloid (0.9% sodium chloride or lactated Ringer's) and blood products as ordered, administer oxygen, monitor vital signs continuously, obtain type and crossmatch, notify the surgeon immediately, and prepare for a possible return to the operating room.

Dehiscence and Evisceration

Dehiscence is partial or complete separation of the wound layers; evisceration is protrusion of abdominal viscera through the open incision — a surgical emergency. Risk peaks 5-8 days postoperatively, before collagen strength matures. Risk factors include obesity, malnutrition, diabetes, corticosteroid use, infection, advanced age, and coughing or straining. The classic warning sign is a sudden gush of serosanguineous (salmon-colored) drainage from the wound; patients often report feeling something "pop" after coughing.

Evisceration response, in order:

1. Stay with the patient and call for help.
2. Cover the protruding organs with sterile dressings moistened with sterile normal saline — never allow viscera to dry out.
3. Do NOT push the organs back into the abdomen.
4. Position supine or low Fowler with knees bent to reduce abdominal tension.
5. Keep the patient NPO and prepare for emergency surgery.
6. Notify the surgeon immediately and monitor for shock.

Surgical Site Infection

Surgical site infection (SSI) typically appears on postoperative days 5-7 (range 3-10). Signs include localized redness, warmth, swelling, increasing pain, induration, purulent drainage, fever, and wound separation. The priority diagnostic step is to obtain a wound culture BEFORE antibiotics are started so therapy can target the causative organism (most commonly Staphylococcus aureus); then administer the ordered antibiotics, perform wound care, and monitor for signs of sepsis. Prevention rests on preoperative antibiotics within 60 minutes of incision, clipper (never razor) hair removal, maintaining normothermia, glucose control, and strict aseptic dressing technique.

Pulmonary Embolism

Pulmonary embolism (PE) is the feared complication of DVT, classically occurring on postoperative days 5-10. The presentation is sudden: acute dyspnea, pleuritic chest pain, tachycardia, tachypnea, and hypoxia, often with anxiety or a sense of impending doom and sometimes hemoptysis.

Emergency response:

1. Stay with the patient and activate the rapid response team.
2. Raise the head of the bed to high Fowler's position.
3. Apply oxygen immediately.
4. Establish IV access; anticipate anticoagulation (heparin infusion) and, for massive PE, thrombolytics or embolectomy.
5. Monitor SpO2, cardiac rhythm, and vital signs continuously; prepare for CT pulmonary angiography.

Massive PE obstructs right ventricular outflow and causes obstructive shock — be prepared to support resuscitation.

Fat Embolism Syndrome

Fat embolism syndrome occurs 12-72 hours after long-bone (especially femur) or pelvic fractures or orthopedic surgery, when fat globules enter the circulation and occlude pulmonary and cerebral microvasculature. The classic triad is hypoxemia, neurologic changes (confusion, agitation), and a petechial rash across the chest, neck, axillae, and conjunctivae — the petechiae are the distinguishing clue on exams. Management is supportive: oxygen (mechanical ventilation may be required), hydration, and close respiratory monitoring. Early stabilization of fractures is the key preventive measure.

Malignant Hyperthermia

An inherited (autosomal dominant) hypermetabolic crisis of skeletal muscle triggered by volatile inhalational anesthetics and succinylcholine. Signs unfold in sequence: unexplained tachycardia, a steep rise in end-tidal CO2 (the most sensitive early indicator), masseter (jaw) muscle rigidity, generalized rigidity, hyperkalemia, acidosis, myoglobinuria, and finally hyperthermia — a late sign. Treatment:

• Stop all triggering agents immediately and hyperventilate with 100% oxygen
• Administer dantrolene sodium 2.5 mg/kg IV, repeated until symptoms subside
• Begin active cooling (iced saline lavage, cooling blankets) and stop cooling at 38-39°C to avoid overshoot hypothermia
• Treat hyperkalemia and metabolic acidosis; monitor urine output for rhabdomyolysis

Every perioperative nurse should know the location of the malignant hyperthermia cart.

Anaphylaxis in the OR and PACU

Common triggers include antibiotics, neuromuscular blocking agents, latex, and contrast dye. Signs include urticaria and flushing, bronchospasm, angioedema, and hypotension — which may be the only visible sign in an anesthetized patient. Response priorities:

1. Stop the suspected agent immediately and call for help.
2. Maintain the airway — anticipate intubation if angioedema is present.
3. Give epinephrine, the first-line drug (0.3-0.5 mg of 1 mg/mL IM into the anterolateral thigh, or IV per protocol in monitored settings).
4. Position supine with legs elevated, administer oxygen, and infuse IV fluids rapidly.

Antihistamines (diphenhydramine) and corticosteroids are second-line adjuncts — they are never substitutes for epinephrine.

Escalation Priorities

Apply universal prioritization frameworks: ABC (airway, breathing, circulation) first, acute over chronic, unstable before stable, and actual problems before potential ones. Sudden respiratory distress, uncontrolled bleeding, new confusion, or rapidly falling blood pressure demands an immediate bedside assessment and activation of the rapid response team — do not delay while waiting for a complete workup. After immediate stabilizing actions, notify the provider using SBAR (situation, background, assessment, recommendation).